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In summary, cancer, congestive heart failure, and hypotension were the best predictors of death among women, whereas age, cancer, hypotension, and tachypnea were the best predictors of mortality among men. Men had an overall higher risk of death than women (hazard ratio 1.7; 95% confidence interval 1.1 to 2.6). However, women with heart failure and PE were more likely to die than men.

Objectives To characterize chest radiographic interpretations in a large population of patients who have received a diagnosis of acute pulmonary embolism and to estimate the sensitivity and specificity of chest radiographic abnormalities for right ventricular hypokinesis that has been diagnosed by echocardiography. Design A prospective observational study at 52 hospitals in seven countries. Patients A total of 2,454 consecutive patients who had received a diagnosis of acute pulmonary embolism between January 1995 and November 1996. Results Chest radiographs were available for 2,322 patients (95%). The most common chest radiographic interpretations were cardiac enlargement (27%), normal (24%), pleural effusion (23%), elevated hemidiaphragm (20%), pulmonary artery enlargement (19%), atelectasis (18%), and parenchymal pulmonary infiltrates (17%). The results of chest radiographs were abnormal for 509 of 655 patients (78%) who had undergone a major surgical procedure within 2 months of the diagnosis of pulmonary embolism: normal results for chest radiograph often accompanied pulmonary embolism after genitourinary procedures (37%), orthopedic surgery (29%), or gynecologic surgery (28%), whereas they rarely accompanied pulmonary emboli associated with thoracic procedures (4%). Chest radiographs were interpreted to show cardiac enlargement for 149 of 309 patients with right ventricular hypokinesis that was detected by echocardiography (sensitivity, 0.48) and for 178 of 485 patients without right ventricular hypokinesis (specificity, 0.63). Chest radiographs were interpreted to show pulmonary artery enlargement for 118 of 309 patients with right ventricular hypokinesis (sensitivity, 0.38) and for 117 of 483 patients without right ventricular hypokinesis (specificity, 0.76). Conclusions Cardiomegaly is the most common chest radiographic abnormality associated with acute pulmonary embolism. Neither pulmonary artery enlargement nor cardiomegaly appears sensitive or specific for the echocardiographic finding of right ventricular hypokinesis, an important predictor of mortality associated with acute pulmonary embolism.

Background.The effect of alteplase versus heparin in pulmonary embolism has not been studied extensively with serial pulmonary angiograms. Objectives.The aim of this randomized, open trial was to evaluate the efficacy and safety of alteplase followed by heparin, versus heparin alone, in 30 patients with angiographically documented pulmonary embolism. Methods.Twenty patients were allocated randomly to a 2-h infusion of alteplase (10 mg bolus, then 90 mg over 2 h) followed by heparin; the other 16 patients were given intravenous heparin at a continuous infusion rate of 1,750 IU/h. Results.The vascular obstruction, assessed by the Miller index at pulmonary angiography, decreased significantly in alteplasetreated patients (p < 0.01) from a baseline of 28.3 ± 2.9 to a value of 24.8 ± 5.2 2 h after the start of infusion; in the heparin group there was no change (from 25.3 ± 5.3 to 25.2 ± 5.4). Mean pulmonary artery pressure decreased significantly from a baseline of 30.2 ± 7.8 mm Hg to 21.4 ± 6.7 in the alteplase group and increased in the heparin group (from 22.3 ± 10.5 to 24.8 ± 11.2 mm Hg). For a subset of patients, lung scans were performed at baseline and on days 7 and 30. There were no differences between the two groups in the follow-up lung scans, but there were significant decreases from the baseline values. Bleeding occurred in 14 of 20 alteplase-treated patients and in 6 of 16 in the heparin group (p = NS). There were three major bleeding episodes in the alteplase group and two in the heparin group. Two patients died after fibrinolysis (one of acute renal failure after cardiac tamponade and one of cardiac arrest after cerebral hemorrhage) and one patient in the heparin group died of recurrent pulmonary embolism. Conclusions.Alteplase resulted in a greater and faster improvement of the angiographic and hemodynamic variables compared with heparin. However, the high frequency of bleeding observed with alteplase in this trial suggests that patients should be carefully selected before thrombolytic therapy is given.

Patients with unstable angina pectoris who remain symptomatic despite medical treatment are at high risk of death and myocardial infarction. The incidence of refractory unstable angina was examined in a consecutive series of 103 patients who received conventional medical treatment with nitrates, beta blockers, calcium antagonists and aspirin. During 48 hours of continuous electrocardiographic monitoring, 24 patients had greater than or equal to 1 anginal attack, 5 of whom had both painful and painless ischemic episodes. In these 24 patients with unstable angina refractory to conventional medical treatment, the short-term efficacy of recombinant tissue-type plasminogen activator (rt-PA) followed by heparin was assessed and compared with heparin alone in a randomized double-blind trial. Recurrences of ischemic attacks during a 72-hour follow-up period were documented in 9 of the 12 patients given heparin alone. All patients experienced at least 1 symptomatic ischemic episode and 1 patient had both painful and painless ischemia. No patient given rt-PA plus heparin had either symptomatic or asymptomatic ischemic attacks during follow-up. Kaplan-Meier curves analysis demonstrated a significantly higher probability of being ischemia free in the group of patients treated with rt-PA followed by heparin than in the group treated with heparin alone (p less than 0.01). Quantitative coronary arteriography failed to reveal any significant changes of ischemia-related lesions before and after each treatment. This study demonstrates that the combination of rt-PA and heparin has a greater protective effect than heparin alone in treating recurrent ischemic episodes in patients with refractory unstable angina.(ABSTRACT TRUNCATED AT 250 WORDS)

Summary Background Pulmonary embolism (PE) remains poorly understood. Rates of clinical outcomes such as death and recurrence vary widely among trials. We therefore established the International Cooperative Pulmonary Embolism Registry (ICOPER), with the aim of identifying factors associated with death. Methods 2454 consecutive eligible patients with acute PE were registered from 52 hospitals in seven countries in Europe and North America. The primary outcome measure was all-cause mortality at 3 months. The prognostic effect of baseline factors on survival was assessed with multivariate analyses. Findings 2110 (86·0%) patients had PE proven by necropsy, high-probability lung scan, pulmonary angiography, or venous ultrasonography plus high clinical suspicion; ICOPER accepted without independent review diagnoses and interpretation of imaging provided by participating centres; 3-month follow-up was completed in 98·0% of patients. The overall crude mortality rate at 3 months was 17·4% (426 of 2454 deaths, including 52 patients lost to follow-up): 179 of 397 (45·1%) deaths were ascribed to PE and 70 of 397 (17·6%) to cancer, and no information on the cause of death was available for 29 patients. After exclusion of 61 patients in whom PE was first discovered at necropsy, the mortality rate at 3 months was 15·3% (365 of 2393 deaths). On multiple-regression modelling, age over 70 years (hazard ratio 1·6 [95% Cl 1·1–2·3]), cancer (2·3 [1·5–3–5]), congestive heart failure (2·4 [1·5–3·7]), chronic obstructive pulmonary disease (1·8 [1·2–2–7]), systolic arterial hypotension (2·9 [1·7–5·0]), tachypnoea (2·0 [1·2–3·2]), and right-ventricular hypokinesis on echocardiography (2·0 [1·3–2·9]) were identified as significant prognostic factors. Interpretation PE remains an important clinical problem with a high mortality rate, Data from ICOPER provide rates and highlight adverse prognostic categories that will help in planning of future trials of high-risk PE patients.